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Claim Page 03 – Entering a Notice of Termination/Revocation – NOTR (8XB)

Claim Page 03 (MAP 1713) contains payer information, diagnosis code information, and physician information.

example

Key:

  • RED = Required field
  • BLUE = Optional field
  • GREEN = Conditional field, dependent on the type of claim
  • PURPLE = System generated field
  • BLACK = Not required field

Field Descriptions for NOTR Page 03 – MAP 1713

Field Name/Requirement

UB-04 Form Locators (FL)

Description

CD
Required

N/A

Enter "Z" on line A.

PAYER
Required

FL 50

FISS Will automatically plug "Medicare" into this field.

RI
Required

FL 52

Release of information.
Valid values are:
I Informed consent to release medical information for condition or diagnoses regulated by Federal Statutes
Y Yes, provider has a signed statement permitting release of information

MEDICAL RECORD NBR
Optional

FL 3b

Beneficiary's medical record number.

ATT PHYS NPI
Required

FL 76

Enter the NPI of the patient's attending physician. If the patient does not have an attending physician, enter the NPI of the certifying physician.

L
Required

FL 76

Enter the last name of the attending physician. If the patient does not have an attending physician, enter the last name of the certifying physician.

F
Required

FL 76

Enter the first name of the attending physician. If the patient does not have an attending physician, enter the first name of the certifying physician.

M
Optional

N/A

Enter the middle initial of the attending physician.

REF PHYS NPI
Conditionally Required

FL 78 and 79

Enter the NPI of the physician responsible for certifying the patient as terminally ill, if different than the attending physician.

L
Conditionally Required

FL 78 and 79

Enter the last name of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

F
Conditionally Required

FL 78 and 79

Enter the first name of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

M
Optional

N/A

Enter the middle initial of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

Additional FISS Claim Pages

Updated: 04.16.2021

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